Full Question & Answer Text (for Search Engines)
Question 1:
You are referred a 68-year-old man who smokes 40 cigarettes per day and has had chronic cough for the past 6 months, increasingly associated with haemoptysis. He also has a dull ache on the left side of his chest, and his chest X-ray reveals a left hilar mass that is suspicious of bronchial carcinoma. You are considering radical radiotherapy in this man. Which of the following is the most significant contraindication to radical radiotherapy?
Options:
- Adenocarcinoma
- Forced expiratory volume in 1 s (FEV1) < 60%
- Malignant pleural effusion
- Superior vena caval obstruction
- Tumour adjacent to the hilum
Correct Answer: Malignant pleural effusion
Explanation:
Correct Answer: C- Malignant pleural effusion Explanation Malignant pleural effusion Studies have shown that the presence of a malignant pleural effusion is predictive of poor outcome with radical radiotherapy. Adenocarcinoma Adenocarcinoma is incorrect. Adenocarcinoma is not a contraindication to radical radiotherapy. Forced expiratory volume in 1 s (FEV1) < 60% Forced expiratory volume in 1 s (FEV1) < 60% is incorrect. It was previously thought that patients with a forced expiratory volume in 1 s (FEV1) of less than 50% were at particular risk of post-radiotherapy pneumonitis, but it has been shown that some patients enrolled in radical radiotherapy trials with severe disease actually showed a small improvement in lung function. Superior vena caval obstruction Superior vena caval (SVC) obstruction is incorrect. SVC obstruction and position of the tumour adjacent to the hilum can increase surgical difficultly, but targeted radiotherapy might not be a problem in the majority of patients. Tumour adjacent to the hilum Tumour adjacent to the hilum is incorrect. Tumour adjacent to the hilum is not a contraindication to radical radiotherapy.
Question 2:
A patient presents with symptoms suggesting bronchiectasis and with abdominal distension, bloating and foul-smelling faeces. What is the most likely diagnosis?
Options:
- Carcinoma of the lung
- Cystic fibrosis
- Goodpasture syndrome
- Granulomatosis with polyangiitis
- Pneumococcus pneumonia
Correct Answer: Cystic fibrosis
Explanation:
Correct Answer: B- Cystic fibrosis Explanation Cystic fibrosis The United States Cystic Fibrosis Foundation Registry data show that as many as 10% of people with cystic fibrosis are not diagnosed until adult life. The main presentation is with respiratory problems, usually recurrent lower respiratory infections with chronic sputum production. Some patients have been diagnosed in the past with bronchiectasis, atypical asthma, nasal polyposis or allergic bronchopulmonary aspergillosis. A new diagnosis of cystic fibrosis has even been described in adults in their seventh decade. Depletion of sodium, chloride and potassium due to excessive sweating, and secondary renal chloride retention, can result in presentation with dehydration and heat exhaustion in an otherwise apparently completely fit adult. Pancreatic insufficiency can lead to steatorrhoea. The vast majority of patients with cystic fibrosis can be diagnosed by a sweat test. Carcinoma of the lung Carcinoma of the lung is incorrect. Lung carcinoma would typically present with breathlessness, cough, weight loss, chest pain or haemoptysis. The history here suggests bronchiectasis and intestinal malabsorption, which are not typical presenting features of lung malignancy. Goodpasture syndrome Goodpasture syndrome is incorrect. Bronchiectasis and intestinal malabsorption are not associated with Goodpasture syndrome, making this an unlikely diagnosis based on the history provided. Granulomatosis with polyangiitis Granulomatosis with polyangiitis is incorrect. Bronchiectasis and intestinal malabsorption are not associated with granulomatosis with polyangiitis. This diagnoses is unlikely based on this history. Pneumococcus pneumonia Pneumococcus pneumonia is incorrect. There is clearly more going on in this case than an acute pneumonia. The history given is of bronchiectasis, not an uncomplicated pneumonia. Pneumococcal pneumonia is not associated with intestinal malabsorption.
Question 3:
A 50-year-old sales representative with a body mass index (BMI) of 34 kg/m2 is referred to the Sleep Clinic because he keeps falling asleep at the wheel. His wife complains that he keeps her awake all night with his snoring. A sleep study confirms moderate sleep apnoea. He has been warned not to return to driving until he has been treated and his symptoms are under control. Which one of the treatments below would be the most appropriate management in this case?
Options:
- Continuous positive airway pressure
- Long-term oxygen therapy
- Mandibular advancement splinting
- Pharyngeal wall surgery
- Tracheostomy
Correct Answer: Continuous positive airway pressure
Explanation:
Correct Answer: A- Continuous positive airway pressure Explanation Continuous positive airway pressure Obstructive sleep apnoea is caused by loss of upper airway pharyngeal muscle tone during rapid eye movement (REM) sleep, which leads to airway obstruction and consequent apnoeic episodes. It affects 1–2% of middle-aged men. CPAP is an effective treatment for sleep apnoea and should be offered (alongside weight loss and alcohol reduction) to this patient. Long-term oxygen therapy Long-term oxygen therapy is incorrect. Long-term oxygen therapy is really only an adjunct in patients who have co-existent lung conditions. Mandibular advancement splinting Mandibular advancement splinting is incorrect. Many trials have looked at the effectiveness of mandibular advancement splints (a tailor-made mouthpiece which helps to keep the jaw forward and aids upper airway muscle tone when asleep). Mandibular advancement splints are recommended as second-line therapy where patients tolerate them or can be used as a first-line treatment in mild sleep apnoea.
Pharyngeal wall surgery
Pharyngeal wall surgery is incorrect. Surgery is really a last-ditch attempt to solve the problem. Tracheostomy Tracheostomy is incorrect. Tracheostomy is not used to treat sleep apnoea.
Question 4:
A 56-year-old man with confirmed squamous-cell carcinoma of the right upper lobe of the lung has a normal FEV1 and normal serum biochemistry. Which one of the following investigations is most appropriate to assess operability?
Options:
- Bone scan
- Chest computed tomography
- Differential perfusion lung scan
- Measurement of total lung capacity
- Sputum cytology
Correct Answer: Chest computed tomography
Explanation:
Correct Answer: B- Chest computed tomography Explanation Chest computed tomography Chest computed tomography is the best method for staging squamous-cell carcinoma of the lung. This would indicate the extent of involvement and would inform the surgical approach. Five-year survival rates are > 75% in stage I disease (no nodes, tumour confined within the visceral pleura) and 55% in stage II disease, which includes resection in patients with ipsilateral peribronchial or hilar node involvement. Bone scan Bone scan is incorrect. A bone scan is not required as there is no clinical, haematological or biochemical evidence of tumour spread to bony sites. Differential perfusion lung scan Differential perfusion lung scan is incorrect. Differential perfusion lung scans are not helpful in staging. Measurement of total lung capacity Measurement of total lung capacity is incorrect. Measurement of total lung capacity is not helpful in staging. Sputum cytology Sputum cytology is incorrect. Sputum cytology is irrelevant, as the diagnosis has already been established.
Question 5:
The anatomical dead space can be used to calculate alveolar ventilation by subtracting it from the tidal volume and multiplying the result by the respiratory rate. What would you expect the normal anatomical dead space to be in a healthy adult male?
Options:
- 50 ml
- 150 ml
- 250 ml
- 350 ml
- 450 ml
Correct Answer: 150 ml
Explanation:
Correct Answer: B-150 ml Explanation 150 ml This is a know it or you don’t question. The normal anatomical dead space is approximately 150 ml. If we take the tidal volume to be about 500 ml and the respiratory rate to be about 15/min, this gives a normal alveolar ventilation of (500 – 150) × 15 = 5250 ml/min. The dead space can be increased in diseases that cause an additional physiological dead space, where parts of lung do not take part in gas exchange (eg pneumonia). 50 ml 50ml is incorrect. The normal anatomical dead space is approximately 150ml in a healthy adult. 250 ml 250ml is incorrect. The normal anatomical dead space is approximately 150ml, but dead space may be abnormally increased in diseases where parts of the lung do not take part in gas exchange. 350 ml 350ml is incorrect. Total dead space is the sum of anatomical dead space and alveolar dead space. This can be increased with conditions such as pulmonary embolism and low cardiac output. 450 ml 450ml is incorrect. The normal value for dead space volume (in mL) is approximately the lean mass of the person in pounds and is approximately a third of the resting tidal volume (between 400-500ml in an adult).
Question 6:
A 62-year-old housewife presents with a 2-month history of lethargy associated with shortness of breath. She has never smoked and takes no medication. Her chest X-ray shows multiple round lesions, increasing in size and numbers at the base, and bulky hilar lymph nodes. Urine testing reveals 2+ haematuria, but no protein. What is the most likely diagnosis?
Options:
- Lung abscesses
- Pulmonary metastases
- Rib fractures
- Silicosis
- Tuberculosis
Correct Answer: Pulmonary metastases
Explanation:
Correct Answer: B- Pulmonary metastases Explanation Pulmonary metastases This lady is likely to have a primary renal cell carcinoma with pulmonary metastases. Multiple metastases range enormously in size and number, from ‘cannon balls’ to miliary shadowing, and can be accompanied by hilar lymphadenopathy or pleural effusion. The most common underlying tumours are breast, colon, renal and lung primaries, but other tumours (that are amenable to chemotherapy) can metastasise to the lung, such as testicular cancer and choriocarcinoma. Diagnosis can be achieved by cytology or histology on various samples from the pleura or lung, and can occasionally be made from cytology of expectorated or induced sputum. Lung abscesses Lung abscesses is incorrect. Lung abscesses are rounded lesions, but air/fluid levels would be visible. There are also no infective symptoms described here, making lung abscesses unlikely. Rib fractures Rib fractures is incorrect. No part in the description of this case is suggestive of rib fractures. Silicosis Silicosis is incorrect. Silicosis is characterised by pulmonary nodules, but these are usually small and predominantly affect the upper lobes. Silicosis is not associated with haematuria. Hilar nodes classically show ‘eggshell’ calcification. Tuberculosis Tuberculosis is incorrect. Tuberculosis can present with lung lesions, lymphadenopathy and lethargy; however, the description of the lesions as round with increasing size and numbers at the base is more in keeping with lung metastases. There is no mention of fever, night sweats or productive cough. If renal TB was suspected it is likely there would be proteinuria as well as haematuria.
Question 7:
A 30-year-old woman with a history of asthma presents for review. She has been taking 400 µg bd of beclometasone and salbutamol as required, which she is using with increasing frequency. What is the best-fit next change to her therapy?
Options:
- Add in a long-acting inhaled ß2-agonist
- Change her inhaled steroid to fluticasone
- Do nothing
- Trial of monteleukast
- Increase her regular repeat prescriptions for salbutamol
Correct Answer: Trial of monteleukast
Explanation:
Correct Answer: D- Trial of monteleukast Explanation Trial of monteleukast In the event that control of symptoms isn’t achieved with lower doses of inhaled corticosteroids, addition of a leukotriene receptor antagonist such as monteleukast is preferred. In the event a trial of therapy is not successful, then a long-acting beta-2 agonist should be introduced. Add in a long-acting inhaled ß2-agonist Add in a long-acting inhaled ß2-agonist is incorrect.
Although this was formerly the recommended next step in NICE guidelines, a trial of leukotriene receptor antagonist is now preferred. In the event the trial is unsuccessful then a long-acting inhaled beta-2-agonist should be introduced. Change her inhaled steroid to fluticasone Change her inhaled steroid to fluticasone is incorrect. Changing her steroid is not appropriate management here, she requires additional therapy. Do nothing Do nothing is incorrect. This lady has uncontrolled asthma on her current regimen. She therefore requires a change in her management. Increase her regular repeat prescriptions for salbutamol Increase her regular repeat prescriptions for salbutamol is incorrect. Salbutamol should be used as rescue therapy and in well-controlled asthma should not need to be used more than a few times a week. If salbutamol is required for relief of symptoms more than this then maintenance treatment should be ‘stepped up’ as per BTS/SIGN guidelines. This lady would benefit from Montelukast, (as per the NICE 2017 guidelines).
Question 8:
A 62-year-old man who underwent treatment for tuberculosis 8 years ago presents via his GP complaining of haemoptysis. He also says that over the past 3 months he has had night sweats on a few occasions each week and a chronic cough. He smokes ten cigarettes per day. On examination he is mildly pyrexial (37.4°C) and his blood pressure is 142/89 mmHg. Auscultation of the chest reveals evidence of consolidation affecting the right upper lobe. Investigations show: haemoglobin 11.9 g/dl, white cell count 11.1 × 109/l, platelets 190 × 109/l, sodium 138 mmol/l, potassium 4.8 mmol/l, creatinine 105 μmol/l. The chest X-ray shows a right upper-lobe cavitating lesion. Aspergillus precipitins are positive. Which of the following is the most likely diagnosis?
Options:
- Allergic bronchopulmonary aspergillosis
- Aspergilloma
- Invasive aspergillosis
- Lung cancer
- Reactivated tuberculosis
Correct Answer: Aspergilloma
Explanation:
Correct Answer: B- Aspergilloma Explanation Aspergilloma Aspergilloma is known to occur in patients who have had previous cavitating lung disease, such as tuberculosis. It is associated with positive Aspergillus precipitins. Surgical resection is successful as long as the patient’s preoperative lung function is good enough to tolerate the procedure. Other treatment options include chronic long- term therapy with antifungals such as itraconazole or locally delivered amphotericin B. If bleeding becomes severe, selective bronchial artery embolisation may be considered. Allergic bronchopulmonary aspergillosis Allergic bronchopulmonary aspergillosis is incorrect. Allergic bronchopulmonary aspergillosis would be associated with more widespread, patchy shadowing. It presents with symptoms akin to asthma and also expectoration of mucous plugs. Investigations would show a raised eosinophil count, raised total IgE and raised IgE to Aspergillus. Invasive aspergillosis Invasive aspergillosis is incorrect. Invasive aspergillosis tends to occur in patients who are immunocompromised due to immunosuppressive therapy, haematological malignancy or HIV infection. It is rapidly fatal if untreated and even with intravenous antifungal therapy mortality is high. Lung cancer Lung cancer is incorrect. The history here is more suggestive of infection than malignancy. Reactivated tuberculosis Reactivated tuberculosis is incorrect. Reactivated tuberculosis is a reasonable differential diagnosis, but given the positive Aspergillus precipitins and the presence of a cavity, aspergilloma is more likely.
Question 9:
A 35-year-old woman with recently diagnosed primary pulmonary hypertension asks you some questions regarding treatment options. She is awaiting transfer to a specialist centre for right heart catheterisation. Which of the following is true?
Options:
- She will be able to have children, as long as she is carefully monitored
- She will benefit from taking lisinopril
- She will benefit from taking long-term anticoagulation with warfarin
- She will benefit from taking the oral contraceptive pill
- She will benefit from taking verapamil
Correct Answer: She will benefit from taking long-term anticoagulation with warfarin
Explanation:
Correct Answer: C- She will benefit from taking long- term anticoagulation with warfarin Explanation She will benefit from taking long-term anticoagulation with warfarin All patients with primary pulmonary hypertension (PPH, a syndrome of pulmonary hypertension of unknown aetiology) are at risk of thromboembolic disease. Several uncontrolled studies have suggested a survival benefit from anticoagulation, although no randomised controlled trials exist. She will be able to have children, as long as she is carefully monitored She will be able to have children, as long as she is carefully monitored is incorrect. Pregnancy is poorly tolerated in patients with PPH. She will benefit from taking lisinopril She will benefit from taking lisinopril is incorrect. Angiotensin-converting enzyme (ACE) inhibitors have no useful effect in PPH. She will benefit from taking the oral contraceptive pill She will benefit from taking the oral contraceptive pill is incorrect. Oral contraceptives increase the risk of venous thromboembolism, so are not advised; however, contraception is very important in management of PPH due to pregnancy being poorly tolerated. She will benefit from taking verapamil She will benefit from taking verapamil is incorrect. Vasodilator studies are performed in patients with PPH to assess vasodilator response. However, verapamil is not used because it has negatively inotropic effects.
Question 10:
A 25-year-old man suffers a spontaneous pneumothorax which is aspirated in the Emergency Department. He has no history of previous chest disease, but is noted to be tall and thin when reviewed in the department, at over 6 feet in height with a BMI of 20. He wants to go travelling, including undertaking a scuba diving course in Thailand. What advice do you give him?
Options:
- He can scuba dive after 3 months
- He can scuba dive after 6 months
- He may fly again after one year
- He should never scuba dive again
- He should not fly again but may scuba dive within 4 weeks
Correct Answer: He should never scuba dive again
Explanation:
Correct Answer: D- He should never scuba dive again Explanation He should never scuba dive again British Thoracic Society guidelines state that patients who have had spontaneous pneumothorax should avoid scuba diving in the future unless they are treated by bilateral surgical pleurectomy and associated with normal lung function and thoracic CT scan performed after surgery. This is because of the risk of significant expansion of pneumothorax during diving ascent. He can scuba dive after 3 months He can scuba dive after 3 months is incorrect. British Thoracic Society guidelines state that patients who have had spontaneous pneumothorax should avoid scuba diving in the future unless they are treated by bilateral surgical pleurectomy and associated with normal lung function and thoracic CT scan performed after surgery. This is because of the risk of significant expansion of pneumothorax during diving ascent. He can scuba dive after 6 months He can scuba dive after 6 months is incorrect. British Thoracic Society guidelines state that patients who have had spontaneous pneumothorax should avoid scuba diving in the future unless they are treated by bilateral surgical pleurectomy and associated with normal lung function and thoracic CT scan performed after surgery. This is because of the risk of significant expansion of pneumothorax during diving ascent. He may fly again after one year He may fly again after 1 year is incorrect. Medical guidelines suggest that patients may fly as little as 5 days after a treated pneumothorax, as long as a check X-ray proves that air has been successfully reabsorbed and lung expansion has been restored. He should not fly again but may scuba dive within 4 weeks He should not fly again but may scuba dive within 4 weeks is incorrect. Medical guidelines suggest that patients may fly as little as 5 days after a treated pneumothorax, as long as a check X-ray proves that air has been successfully reabsorbed and lung expansion has been restored.
Question 11:
A 25-year-old smoker of five cigarettes per day comes to the clinic complaining of recurrent haemoptysis that he has had for the past 2 years. He has been treated for intermittent cough and respiratory infections over the past few years. On examination he looks a little thin but is otherwise well. Respiratory examination raises the suggestion of left upper-lobe collapse. There are no other abnormal findings. Investigation: Hb 11.9 g/dl WCC 5.9 x 109/l PLT 187 x 109/l Sodium 141 mmol/l Potassium 4.2 mmol/l Creatinine 110 µmol/l The chest X-ray shows left upper-lobe collapse. Which of the following is the most likely diagnosis?
Options:
- Bronchial carcinoid
- Bronchial carcinoma
- Bronchiectasis
- Inhaled foreign body
- Left upper-lobe pneumonia
Correct Answer: Bronchial carcinoid
Explanation:
Correct Answer: A- Bronchial carcinoid Explanation Bronchial carcinoid Recurrent haemoptysis with segmental collapse is a typical presentation of bronchial carcinoid. The prolonged clinical course, without features of carcinoid syndrome, is typical of a bronchial carcinoid tumour. Bronchial carcinoma Bronchial carcinoma is incorrect. Because this patient is relatively well and has limited chest disease, bronchial carcinoid is much more likely than a carcinoma. Bronchiectasis Bronchiectasis is incorrect. No features suggest that there is active infection, which makes both left upper-lobe pneumonia and bronchiectasis unlikely. Inhaled foreign body Inhaled foreign body is incorrect. An inhaled foreign body would be more likely to lie in the right main bronchus and so does not fit with the clinical scenario here. Left upper-lobe pneumonia Left upper-lobe pneumonia is incorrect. No features suggest that there is active infection, which makes both left upper-lobe pneumonia and bronchiectasis unlikely.
Question 12:
A 67-year-old patient with non-small-cell lung cancer complains of difficulty breathing, coughing and swelling of his face, neck, upper body and arms. Superior vena cava syndrome is diagnosed. Which of the following treatments is most likely to be successful in giving early relief of symptoms?
Options:
- Anti-hypertensive drugs
- Chemotherapy
- Corticosteroids
- Radiotherapy
- Surgery
Correct Answer: Radiotherapy
Explanation:
Correct Answer: D- Radiotherapy Explanation Radiotherapy Superior vena cava syndrome (SVCS) is a collection of symptoms caused by the partial blockage of the vein that carries blood from the head, neck, chest and arms to the heart. Symptoms can include difficulty breathing, coughing and swelling of the face, neck, upper body and arms. In rare instances patients complain of hoarseness, chest pain, difficulty swallowing and coughing up blood.
Physical signs of SVCS include swelling of the neck or chest veins, collection of fluid in the face or arms, and rapid breathing. In patients with SVCS secondary to non-small-cell carcinoma of the lung, radiotherapy is the primary treatment of choice. The likelihood of patients benefiting from such therapy is high, but the overall prognosis of these patients is poor. The fractionation schedule for radiotherapy usually includes two to four large initial fractions of 3–4 Gy, followed by daily delivery of conventional fractions of 1.5–2 Gy, up to a total dose of 30–50 Gy. The radiation dose depends on tumour size and radioresponsiveness. The radiation field should include a 2 cm margin around the tumour. Anti- hypertensive drugs Anti-hypertensive drugs is incorrect. Anti-hypertensive therapy will have no influence on the underlying cause of SVCS and is not a key part of immediate management. Chemotherapy Chemotherapy is incorrect. SVC stenting may provide relief of severe symptoms for patients while the histologic diagnosis of the malignancy causing the obstruction is being actively pursued. It may also be indicated in patients in whom chemotherapy or radiation has failed. Corticosteroids Corticosteroids is incorrect. Corticosteroids and diuretics are often used to relieve laryngeal or cerebral oedema related to SVCS, although documentation of their efficacy is questionable. Radiotherapy is the most likely of the options given to be successful in giving early relief of symptoms. Surgery Surgery is incorrect. Surgery for SVCS (surgical bypass) is rarely performed and is generally reserved for patients with advanced intrathoracic disease who have not responded to non-surgical treatments such as radiotherapy, chemotherapy and stenting.
Question 13:
A man came in to the Emergency Department with breathlessness and anterior chest pain. Chest X- ray showed a large pneumothorax on the right side, with midline shift away from the side of the pneumothorax. His pulse was 95 bpm and blood pressure was 95/70 mmHg. What should be done next?
Options:
- Chest drain insertion
- Chest drain insertion under radiographic control
- Needle aspiration in the mid-axillary line
- Repeat chest X-ray after a few hours
- Wide-bore cannula inserted through second intercostal space mid-clavicular line
Correct Answer: Wide-bore cannula inserted through second intercostal space mid-clavicular line
Explanation:
Correct Answer: E- Wide-bore cannula inserted through second intercostal space mid-clavicular line Explanation Wide-bore cannula inserted through second intercostal space mid-clavicular line This man has a large pneumothorax with mediastinal shift and significant symptoms. In the presence of midline shift, the most appropriate initial management would be needle decompression, with placement of an intravenous cannula in the second intercostal space. This should be followed later by placement of a formal chest drain. This is the course of management recommended by British Thoracic Society guidelines. Chest drain insertion Chest drain insertion is incorrect. The midline shift and hypotension indicate tension pneumothorax, which requires immediate needle decompression prior to intercostal drain insertion. Chest drain insertion under radiographic control Chest drain insertion under radiographic control is incorrect. A large pneumothorax should not require radiographic guidance. Nevertheless, this man has signs of tension pneumothorax and requires immediate needle decompression. Needle aspiration in the mid-axillary line Needle aspiration in the mid-axillary line is incorrect. The appropriate site for needle aspiration in tension pneumothorax is the second intercostal space in the mid- clavicular line. Repeat chest X-ray after a few hours Repeat chest X-ray after a few hours is incorrect. This man has evidence of a tension pneumothorax, which is a life-threatening condition and requires urgent intervention with needle decompression.
Question 14:
A 33-year-old man presents with increasing symptoms of severe breathlessness on exercise. Up until the last few months he had been holding down a job as a successful salesman. There is a history of smoking 8–10 cigarettes per day. His father died at a young age (under 50) of severe chest disease. Routine blood tests reveal that this patient is mildly jaundiced with a bilirubin of 90 µmol/l; his aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are also outside the normal range. Chest X-ray reveals basal emphysema. Which diagnosis best fits this clinical picture?
Options:
- α1-Antitrypsin deficiency
- Chronic obstructive pulmonary disease secondary to excessive smoking
- Cirrhosis
- Gilbert syndrome
- Stress
Correct Answer: α1-Antitrypsin deficiency
Explanation:
Correct Answer: A- α1-Antitrypsin deficiency Explanation α1-Antitrypsin deficiency This man, who is under 40 years of age, presents with breathlessness and with radiographic evidence of emphysema. Cigarette smoking acts synergistically to promote the development of emphysema. Hereditary α1- antitrypsin deficiency accounts for around 2% of cases of emphysema. Around 75% of patients with α1-antitrypsin deficiency develop chest pathology and around 15% of patients have associated cirrhosis, the likely diagnosis in this case. Patients with hepatic decompensation might be offered liver transplantation; those with chest pathology are strongly advised to stop smoking. Around one in ten northern Europeans carry a gene mutation for this deficiency. Heterozygotes may be at increased risk of lung disease if they smoke; homozygotes are pre-disposed to presentation with early emphysema. Chronic obstructive pulmonary disease secondary to excessive smoking Chronic obstructive pulmonary disease secondary to excessive smoking is incorrect. The smoking history is not excessive here. Basal emphysema is classically associated with α1-antitrypsin deficiency, which is one clue that this case is not just smoking-related COPD. Also, COPD due to excessive smoking would not explain the hepatic dysfunction that ths man has (which is another feature suggestive of α1-antitrypsin deficiency). Cirrhosis Cirrhosis is incorrect. Cirrhosis could explain abnormal liver function, but would not explain the basal emphysema that this gentleman has, despite his fairly modest smoking history and young age. Gilbert syndrome Gilbert syndrome is incorrect. Gilbert syndrome is associated with elevated bilirubin. It is not associated with elevated liver enzymes, nor is it associated with emphysema. Stress Stress is incorrect. Stress cannot explain his emphysema or his abnormal liver function tests.
Question 15:
You see a 70-year-old woman in the clinic with chronic obstructive pulmonary disease. She currently smokes 10 cigarettes per day and is breathless when walking around her house and garden. She has an FEV1 of 1.2 litres (40% predicted) and an FVC of 2.0 litres (50% predicted). She had minimal bronchodilator reversibility following nebulised salbutamol. Her oxygen saturations are 93% on air and she takes salbutamol only as needed. What would be the next treatment option for her?
Options:
- Inhaled steroids as monotherapy
- Long-acting anticholinergic inhaler
- Long-term domiciliary oxygen
- Oral leukotriene-receptor antagonist
- Oral theophylline
Correct Answer: Long-acting anticholinergic inhaler
Explanation:
Correct Answer: B- Long-acting anticholinergic inhaler Explanation Long-acting anticholinergic inhaler This woman has severe chronic obstructive pulmonary disease (COPD) on the evidence of her spirometry and is now symptomatic. Clearly she needs to stop smoking, but the next treatment would be a long-acting anticholinergic inhaler or high-dose inhaled corticosteroids combined with a long-acting β-2 agonist Inhaled steroids as monotherapy Inhaled steroids as monotherapy is incorrect. Inhaled steroids are used in COPD but not as montherapy, only in combination with a long-acting bronchodilator. Long-term domiciliary oxygen Long-term domiciliary oxygen is incorrect. She does not fulfil the requirements for long-term oxygen therapy because she smokes and her oxygen saturations indicate her pO2 is likely > 7.3 kPa. Oral leukotriene-receptor antagonist Oral leukotriene-receptor antagonist is incorrect. Oral leukotriene-receptor antagonists are not used in the management of COPD. Oral theophylline Oral theophylline is incorrect. Oral theophylline is used, but only after adequate inhaled therapy is established. Oral theophyllines are favoured less in recent COPD management guidelines.
Question 16:
A 58-year-old man comes to the Emergency Department. He has been treated at home with nebulisers and oral steroids for a chronic obstructive pulmonary disease (COPD) exacerbation but continues to deteriorate. When you see him he has been in the department for 30 min and is on his third salbutamol nebuliser. On examination he looks tired and cyanosed. He has poor air entry and wheeze on auscultation of his chest. Arterial blood gasses on 24% O2 (turned down from 28% 15 min earlier) pO2 8.0 kPa PCO2 9.2 kPa pH 7.2 15 min earlier pO2 8.2 kPa pCO2 8.5 kPa pH 7.31 Which of the following is the next appropriate management step?
Options:
- Doxapram
- Further nebulisers
- Intubation and ventilation
- Non-invasive positive pressure ventilation
- Sodium bicarbonate
Correct Answer: Non-invasive positive pressure ventilation
Explanation:
Correct Answer: D- Non-invasive positive pressure ventilation Explanation Non-invasive positive pressure ventilation This patient has CO2 retention, hypoxia and respiratory acidosis, which has worsened over the past 15 min, despite reducing his inspired O2. As such the next logical option is NIPPV as he is not responding to medical therapy. Doxapram Doxapram is incorrect. Although doxapram is a respiratory stimulant it is inferior to NIPPV in terms of outcomes. Further nebulisers Further nebulisers is incorrect. The patient has already deteriorated despite 3 nebulisers. He requires help with his ventilator requirements via NIPPV as the next most appropriate step. Intubation and ventilation Intubation and ventilation is incorrect. Intubation and ventilation may be considered if the patient fails to respond to NIPPV.
Sodium bicarbonate
Sodium bicarbonate is incorrect. Sodium bicarbonate will not affect his CO2 retention and may exacerbate fluid retention.
Question 17:
A 65-year-old man complains of lethargy, fever, dry cough, headache, chest pain and increasing shortness of breath. He returned from a cruise 2 days ago. His chest X-ray shows bilateral consolidation and his Po2 is 8.35 kPa. What is the most likely diagnosis?
Options:
- Legionella pneumonia
- Pulmonary embolism
- Sarcoidosis
- Small-cell carcinoma of the lung
- Tuberculosis
Correct Answer: Legionella pneumonia
Explanation:
Correct Answer: A- Legionella pneumonia Explanation Legionella pneumonia Legionella infection is the cause of around 2–5% of cases of community-acquired pneumonia admitted to hospital, although there is wide geographical and seasonal variation. Infection tends to lead to moderate or severe infection rather than mild illness, and most patients require hospital admission within 5–7 days of the start of symptoms. The incubation period is usually 2–10 days, with a mean of 7 days; males are two to three times more frequently affected than females. Infection at the extremes of age is rare and the highest incidence is in the 40- to 70-year-old age group, with a mean age of 53 years. People especially at risk include:
• Cigarette smokers • Alcoholics • Diabetics • People with a chronic illness • People receiving corticosteroids or immunosuppressive therapy Consequently, the type of patient who requires admission to hospital is particularly at risk from a nosocomial source. Typically, the illness starts fairly abruptly with high fever, shivers, severe headache and muscle pains. Upper respiratory tract symptoms, herpes labialis and skin rashes are uncommon. The cough is usually dry initially, but dyspnoea is common and the illness often progresses quickly. Sometimes there is a history of a recent hotel holiday abroad or a stay in hospital, which can alert the clinician to the possible diagnosis. The patient commonly looks toxic and ill, with a high fever over 39 °C. Confusion and delirium or diarrhoea can dominate the clinical picture, masking the true diagnosis of pneumonia. Focal neurological signs, particularly of a cerebellar type, have been described. Amnesia on recovery is common. Pulmonary embolism Pulmonary embolism is incorrect. This situation clearly describes a case of pneumonia with fever and bilateral consolidation on chest radiography. Therefore, pulmonary embolism is unlikely. Sarcoidosis Sarcoidosis is incorrect. This situation clearly describes a case of pneumonia with fever and bilateral consolidation on chest radiography. Therefore, sarcoidosis is unlikely. Small-cell carcinoma of the lung Small-cell carcinoma of the lung is incorrect. This situation clearly describes a case of pneumonia with fever and bilateral consolidation on chest radiography. Therefore, small-cell carcinoma of the lung is unlikely. Tuberculosis Tuberculosis is incorrect. The history indicates respiratory infection and hence, although tuberculosis is a possibility, Legionella pneumonia is more likely given the dry cough, headache and travel history, where he may have been exposed to a large-scale air conditioning system and complex potable water systems.
Question 18:
A 72-year-old former coal-miner visits you for review. He reports having frequently worked at the coal face in cramped conditions, with exposure to a large volume of coal dust. He says he has had increasing symptoms of cough and shortness of breath over the past few years, but continues to smoke 10–15 cigarettes per day. His chest X-ray reveals a large number of small, round opacities within the lung fields, with almost complete obscuration of normal lung markings. Which diagnosis fits best with this clinical picture?
Options:
- Asthma
- Category 1 pneumoconiosis
- Category 2 pneumoconiosis
- Category 3 pneumoconiosis
- Chronic obstructive pulmonary disease
Correct Answer: Category 3 pneumoconiosis
Explanation:
Correct Answer: D- Category 3 pneumoconiosis Explanation Category 3 pneumoconiosis The severity of X-ray changes described here suggests category 3 (the most severe) form of pneumoconiosis. The 0–3 classification is defined by the international labour organisation and reflects an increasing density of small opacities on the chest radiograph. Asthma Asthma is incorrect. The abnormal chest X-ray appearances and occupational history given make pneumoconiosis more likely than asthma. Category 1 pneumoconiosis Category 1 pneumoconiosis is incorrect. Category 1 pneumoconiosis is the least severe, with fewer opacities and normal lung markings clearly visible. Category 2 pneumoconiosis Category 2 pneumoconiosis is incorrect. Category 2 pneumoconiosis is less severe, with a number of opacities but normal lung markings still visible. Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is incorrect. Although he could have some smoking- related COPD, his chest X-ray is diagnostic in the presence of his occupational history of category 3 pneumoconiosis.
Question 19:
A 42-year-old salesman was admitted with a diagnosis of pneumonia. His chest X-ray showed a hazy opacity in the right lower lobe and mid-zone. He is allergic to erythromycin. Blood investigations showed hyponatraemia and a slight rise in the level of liver aminotransferases. On the 5th day after starting medication he became acutely jaundiced and his liver aminotransferase levels became very high. He also complained of discoloration of his urine, though dipstick testing did not show haematuria. Which one of the following drugs probably caused the jaundice?
Options:
- Amoxicillin
- Ciprofloxacin
- Clarithromycin
- Flucloxacillin
- Rifampicin
Correct Answer: Rifampicin
Explanation:
Correct Answer: E- Rifampicin Explanation Rifampicin This patient has Legionella pneumonia and so rifampicin was prescribed. However, rifampicin is a hepatic-enzyme inducer and its use can lead to acute jaundice, with a rise in liver aminotransferases. It also causes red or orange discoloration of the urine and other body fluids and patients should be warned about this side- effect.Monotherapy with rifampicin is associated with the development of resistance and is not generally used to treat Legionella pneumonia. As this patient is allergic to the macrolides, ciprofloxacin would be the other drug of choice. Amoxicillin Amoxicillin is incorrect. Amoxicillin is not an effective treatment for Legionella pneumonia and should not be prescribed in a case such as this. Regardless, hepatotoxicity from amoxicillin is ucommon. Ciprofloxacin Ciprofloxacin is incorrect. Ciprofloxacin may be used to treat Legionella pneumonia in macrolide allergic patients but it is not usually associated with hepatotoxicity. Furthermore, the discolouration of urine is suggestive of rifampicin which is more likely to be associated with hepatotoxicity and is therefore the correct answer. Clarithromycin Clarithromycin is incorrect. He is allergic to macrolides so would not have been prescribed clarithromycin. Flucloxacillin Flucloxacillin is incorrect. Flucloxacillin can be associated with hepatotoxicity but this is rare. The risk of hepatotoxicity is increased with use over 2 weeks and with increased patient age. Furthermore, flucloxacillin is not an effective treatment for Legionella pneumonia and should not be prescribed in a case such as this.
Question 20:
You are reviewing a 67-year-old man with a history of chronic obstructive pulmonary disease (COPD) who comes to the clinic. He feels increasingly short of breath despite maximal therapy with home nebulisers, high- dose Seretide and tiotropium. Which of the following features would drive you towards a prescription for long-term oxygen therapy (LTOT) with respect to two blood gases sampled > 3 weeks apart?
Options:
- PaCO2 5.6 kPa
- PaO2 7.2 kPa
- PaO2 8.4 kPa with secondary polycythaemia
- PaO2 8.6 kPa with right heart failure
- PaO2 8.8 kPa
Correct Answer: PaO2 7.2 kPa
Explanation:
Correct Answer: B- PaO2 7.2 kPa Explanation
PaO2 7.2 kPa NICE guidance on LTOT suggests it should be used in patients with PaO2 < 7.3 kPa measured when disease is stable, three or more weeks apart. Where O2 is 7.3 kPa or greater but less than 8 kPa when stable, and there is secondary polycythaemia, peripheral oedema, nocturnal hypoxaemia or pulmonary hypertension, LTOT may also be prescribed. CO2 is not a criterion for prescription of LTOT.
PaCO2 5.6 kPa
PaCO2 5.6 kPa is incorrect. This is a normal PaCO2. Regardless, the degree of hypoxia determines the need for oxygen prescription.
PaO2 8.4 kPa with secondary polycythaemia
PaO2 8.4 kPa with secondary polycythaemia is incorrect. NICE guidance on LTOT suggests it should be used in patients with PaO2 < 7.3 kPa measured when disease is stable, three or more weeks apart. Where O2 is 7.3 kPa or greater but less than 8 kPa when stable, and there is secondary polycythaemia, peripheral oedema, nocturnal hypoxaemia or pulmonary hypertension, LTOT may also be prescribed. CO2 is not a criterion for prescription of LTOT.
PaO2 8.6 kPa with right heart failure
PaO2 8.6 kPa with right heart failure is incorrect. NICE guidance on LTOT suggests it should be used in patients with PaO2 < 7.3 kPa measured when disease is stable, three or more weeks apart. Where O2 is 7.3 kPa or greater but less than 8 kPa when stable, and there is secondary polycythaemia, peripheral oedema, nocturnal hypoxaemia or pulmonary hypertension, LTOT may also be prescribed. CO2 is not a criterion for prescription of LTOT.
PaO2 8.8 kPa
PaO2 8.8 kPa is incorrect. NICE guidance on LTOT suggests it should be used in patients with PaO2 < 7.3 kPa measured when disease is stable, three or more weeks apart. Where O2 is 7.3 kPa or greater but less than 8 kPa when stable, and there is secondary polycythaemia, peripheral oedema, nocturnal hypoxaemia or pulmonary hypertension, LTOT may also be prescribed. CO2 is not a criterion for prescription of LTOT.
